Date of Application
Name (Last, First, Middle)
Position applying for
1st shift (8 am - 4 pm)2nd shift (4 pm - 12 am)3rd shift (12 am - 8 am)
Were you referred by a current employee?
If yes, employee's name
Are you over 18 years of age?
Were you previously employed by us?
If yes, give dates and positions/Dates
Are you legally authorized for employment in the United States?
(If offered employment you will be required to provide documentation to verify eligibility.)
Have you ever been fired or asked to resign from a job?
If yes, please explain:
Have you ever been convicted of a major crime (felony) in the past?
(A conviction will not automatically disqualify an applicant from a particular job.)
If yes, please give the conviction date, location, and the nature of the offense:
High School Name and Address
Did you graduate?
College Name and Address
College Course or Major
Business or Trade School Name
Business or Trade School Course or Major
Other schooling Name
Other schooling Course or Major
Other schooling degree
Special Skills, Qualifications, Considerations
Summarize special skills and qualifications, volunteer activities, military experience, employment or other activities related to the job you are seeking
List three professional or personal references (not relatives).
List present and past employment, beginning with your most recent.
Name and address of company:
Reason for Leaving
May we contact for reference?
I hereby certify that all information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I authorize Midstates Group to verify the accuracy and information provided. I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.
I understand that submission of an application does not guarantee employment. If hired, I will be employed at will; I understand that this means that either I or the employer is free to terminate the employment relationship at any time with or without cause or prior notice. I understand that no representative of the company, other than the CEO, has any authority to enter into an agreement for employment for any specified period of time or, in any way, to modify the at-will nature of the employment relationship.
I understand that if I am offered employment, it could result in a pre-employment drug screening and background check at the expense of Midstates Group and that this is a condition of employment.
I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Midstates Group.
By checking below I acknowledge that I have read, understood and agree to the above statements.
DO NOT CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
This application is valid for ninety (90) days from the date submitted. If you would like to be considered for job openings more than ninety (90) days from the date signed, please submit a new application.